Provider Demographics
NPI:1659728061
Name:AMUNDARAY DIAZ, EMMANUEL JOSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:JOSE
Last Name:AMUNDARAY DIAZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ALBOLOTE AVENUE
Mailing Address - Street 2:CONDO. CHALETS DEL PARQUE, APT 2A3 MAILBOX #136
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-565-5272
Mailing Address - Fax:
Practice Address - Street 1:735 AVE PONCE DE LEON STE 510
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-5027
Practice Address - Country:US
Practice Address - Phone:787-250-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0608431223S0112X
PR3420122300000X
OH30025184122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery